To optimize ROI and results, transitional care should target patients with multiple, chronic or catastrophic conditions rather than applied as a one-size-fits-all intervention.

This philosophy that transitional care is better for some patients than others drives the award-winning Community Care of North Carolina (CCNC) care transition management program. The ten-year-old program identifies patients most likely to benefit from these resource-intensive interventions, as well as those who won't.

In Home Visits for Clinically Complex Patients: Targeting Transitional Care for Maximum Outcomes and ROI Carlos Jackson, Ph.D., CCNC director of program evaluation, describes how his organization discerns and manages a priority population for transitional care, and why home visits have risen to the forefront of activities by CCNC transitional care managers.

The CCNC transitional care (TC) approach for North Carolina Medicaid beneficiaries with multiple chronic conditions resulted in more than 2,200 fewer readmissions and 8,000 fewer inpatient admissions in 2014 as compared to 2008. The program was awarded the inaugural Hearst Health Prize for Population Health in early 2016.

This 25-page special report provides the following details:

Statistical methods for determining the population likely to meaningfully benefit from transitional care;

The typical CCNC transitional care high-priority patient;

Flagging TC priority patients for home visits;

Comparison of time to readmission for TC patients versus non-TC patients, by severity of conditions;

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